Chapter 12

Inflammation and Healing

KEY POINTS
INFLAMMATORY RESPONSE
• The inflammatory response is a sequential reaction to cell injury. It neutralizes and dilutes the
inflammatory agent, removes necrotic materials, and establishes an environment suitable for
healing and repair.
• The mechanism of inflammation is basically the same regardless of the injuring agent. The
intensity of the response depends on the extent and severity of injury and the reactive capacity
of the person.
• The inflammatory response can be divided into a vascular response, a cellular response,
formation of exudate, and healing.
• The vascular response results in vasodilation causing hyperemia (increased blood flow in the
area) and increased capillary permeability. These actions result in redness, heat, and swelling
at the site.
• During the cellular response, neutrophils and monocytes move to the inner surface of the
capillaries and then through the capillary wall to the site of injury.
• Exudate consists of fluid and leukocytes that move from the circulation to the site of injury.
The nature and quantity of exudate depend on the type and severity of the injury and the
tissues involved.
• Several chemical mediators aid in the inflammatory process.
• The complement system is an enzyme cascade consisting of pathways to mediate
inflammation and destroy invading pathogens. Major functions of the complement system are
enhanced phagocytosis, increased vascular permeability, chemotaxis, and cellular lysis.
• PGs are generally considered proinflammatory and are potent vasodilators contributing to
increased blood flow and edema formation. PGs have a role in sensitizing pain receptors to
stimuli that would normally be painless.
• The local response to inflammation includes the manifestations of redness, heat, pain,
swelling, and loss of function.
• Systemic manifestations of inflammation include an increased WBC count with a shift to the
left, malaise, nausea and anorexia, increased pulse and respiratory rate, and fever.
• The basic types of inflammation are acute, subacute, and chronic.
• In acute inflammation, the healing occurs in 2 to 3 weeks and usually leaves no residual
damage.
• A subacute inflammation has the features of the acute process but lasts longer.
• Chronic inflammation lasts for weeks, months, or even years.
NURSING AND INTERPROFESSIONAL MANAGEMENT: INFLAMMATION
• Early recognition of inflammation is important so that appropriate treatment can begin.
• Treatment depends on the cause. This may include fever management, rest, drug therapy, or
specific treatment of the injured site. Immediate treatment may prevent the extension and
complications of inflammation.
• Drug therapy to decrease the inflammatory response and lower the body temperature involves the
use of aspirin, acetaminophen, some nonsteroidal antiinflammatory drugs (NSAIDs), and
corticosteroids.
• RICE (Rest, Ice, Compression, Elevation) is a key concept in treating soft tissue injuries.
Healing Process
• Healing includes 2 major components of regeneration and repair. Regeneration is the
replacement of lost cells and tissues with cells of the same type. Repair is the more common

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 type of healing and usually results in scar formation. Repair occurs by primary, secondary,
and tertiary intention.
• Primary intention takes place when wound margins are neatly approximated, such as with a
surgical incision or a paper cut. There are 3 phases of the continuum for this process: initial,
granulation, and maturation.
• Secondary intention wounds occur from trauma, injury, and infection and have large amounts
of exudate and wide, irregular wound margins with extensive tissue loss. These wounds may
have edges that cannot be brought together.
• Tertiary intention occurs with delayed suturing of a wound in which 2 layers of granulation
tissue are sutured together.
• Wounds are classified by their cause (surgical or nonsurgical; acute or chronic) and depth of
tissue affected (superficial, partial thickness, or full thickness).
NURSING AND INTERPROFESSIONAL MANAGEMENT: WOUND
HEALING
• Perform a thorough assessment of wounds on admission and on a regular basis.
Observation and recording of wound characteristics are essential tasks.
• The purposes of wound management include (1) cleaning a wound to remove any dirt and debris
from the wound bed, (2) treating infection to prepare the wound for healing, and
(3) protecting a clean wound from trauma so that it can heal normally.
• The type of wound management and dressings needed depends on the causative agent, the degree
of injury, and the patient’s condition.
• The type of wound management and dressings needed depend on the type, extent, and
characteristics of the wound and the phase of healing.
• A variety of adjunctive therapies may be used to aid in wound healing:
• Negative-pressure wound therapy (vacuum-assisted wound closure) uses suction to remove
drainage and speed wound healing.
• Hyperbaric O2 therapy accelerates granulation tissue formation and wound healing.
• Platelet-derived growth factor stimulates wound healing by promoting cell proliferation and
migration.
• Special nutritional measures promote wound healing. A high fluid intake is needed to replace
fluid loss from perspiration and exudate formation. A diet high in protein, carbohydrate, and
vitamins with moderate fat intake is necessary to promote healing.
• Infection control measures, including proper hand hygiene, are important in keeping the wound
free from infection.
• It is important that the patient, the family, or both know how to care for the wound and perform
dressing changes.
• Assist the patient with coping with any body images changes or fear associated with having a
wound.
PRESSURE INJURIES
• A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony
prominence or related to a medical or other device.
• The injury occurs because of intense and/or prolonged pressure or pressure in combination with
shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate,
nutrition, perfusion, co-morbidities, and condition of the soft tissue.
• The clinical manifestations of pressure injuries depend on the extent of the tissue that is involved.
The injury can present as intact skin or an open injury and may be painful.
• Assess patients for pressure injury risk initially on admission and at periodic intervals based on
the patient’s condition and care setting. Use a validated risk assessment tool.

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 • Care of a patient with a pressure injury requires local care of the wound and support measures of
the whole person, including adequate nutrition, pain management, control of other medical
conditions, and pressure relief.
• Local care of the pressure injury may involve debridement, wound cleaning, application of a
dressing, and relief of pressure.
• Maintaining adequate nutrition is an important nursing responsibility and involves the
identification and correction of malnutrition states.
• Pressure injuries affect the quality of life of patients and their caregivers. It is important that the
nurse support the caregiver through the added responsibility of pressure injury treatment.

Chapter 13
Genetics
KEY POINTS
GENETICS
• Genetics is the study of genes and their role in inheritance. Genetics determines the way that
certain traits or conditions are passed down from one generation to another.
• Genomics is the study of all a person’s genes (the genome), including interactions of these genes
with each other and with the person’s environment.
• Genomics includes the study of complex diseases (e.g., heart disease, diabetes mellitus, cancer),
because these diseases are typically caused by a combination of genetic and environmental factors rather
than by a single gene.
Genetic Mutations
• A mutation is any change in the usual DNA sequence. A genetic mutation is like a spelling error
in a gene’s sequence.
• Gene mutations occur in 2 ways. They can be inherited from a parent (germline mutation) or
acquired (somatic mutation) during a person’s lifetime.
• Germline mutations are passed from parent to child.
• Acquired (somatic) mutations occur in the DNA of a cell at some time during a
person’s life. An acquired mutation is passed on to all cells that develop from that single cell.
Inheritance Patterns
• Genetic disorders can be categorized into autosomal dominant, autosomal recessive, or sex-linked
(X-linked) recessive disorders.
• Autosomal dominant disorders are caused by a mutation of a single gene pair
(heterozygous) on a chromosome.
• Autosomal recessive disorders are caused by a mutation in 2 gene pairs (homozygous) on a
chromosome.
• X-linked recessive disorders are caused by a mutation on the X chromosome.
Genetic Disorders
• Genetic disorders can be inherited (person born with altered genetic code) or acquired
(e.g., replication errors, damage to DNA from toxins).
• Genetic disorders can be caused by
• a mutation in a single gene.
• mutations in multiple genes (multifactorial inheritance disorder), which are often related to
environmental factors.
• damage to chromosomes (changes in the number or structure of entire chromosomes).
Genetic Testing
• Genetic testing includes any procedure done to analyze chromosomes or genes that can determine
if a mutation or predisposition to a condition exists.
• Genetic testing may lead to both ethical and social issues.

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• People making decisions about genetic testing should be aware of all the safeguards that have
been developed to maintain confidentiality and actions they need to take to assure information remains
confidential.
• Genetic testing may uncover information that may affect a family member who was not tested.
Interpreting Genetic Test Results
• The results of genetic tests are not always straightforward, which often makes them challenging
to interpret and explain.
• A positive test result means that the laboratory found a change in a particular gene, chromosome,
or protein that was being tested. This result may:
• confirm a diagnosis (e.g., Huntington’s disease)
• indicate that a person is a carrier of a particular genetic mutation (e.g., cystic fibrosis)
• identify an increased risk of developing a disease (e.g., breast cancer)
• suggest a need for further testing
• A positive result of a predictive or presymptomatic genetic test usually cannot establish the
absolute risk of developing a disorder or predict the course or severity of a condition.
• A negative test result means that the laboratory did not find an altered form of the gene,
chromosome, or protein under consideration.
• This result can indicate that a person is not affected by a particular disorder, is not a carrier of a
specific genetic mutation, or does not have an increased risk of developing a certain disease.
• It is possible that the test missed a disease-causing genetic alteration, because many tests cannot
detect all the genetic changes that cause a particular disorder.
Technology Used for Genetic Testing
• DNA fingerprinting begins by extracting DNA from the cells in a sample of blood, saliva, semen,
or other appropriate fluid or tissue.
• Polymerase chain reaction (PCR) is a quick method that provides unlimited copies of a
DNA or RNA sequence using only a small amount of sample.
• DNA microarray (DNA chip) allows the study of genes that are active and that are inactive in
different cell types. This helps to understand (1) how cells function normally and (2) how they are
affected when various genes do not perform properly.
Genome-Wide Association Study (GWAS)
• Genome-wide association study (GWAS) is an approach that involves rapidly scanning complete
sets of DNA, or genomes, of many people to find genetic variations associated with the development or
progression of a particular disease.
• GWAS is particularly useful in finding genetic variations that contribute to multifactorial
inherited disorders, such as cancer, diabetes, and heart disease.
Pharmacogenomics and Pharmacogenetics
• Pharmacogenomics is the study of genetic variability of drug responses due to variation in
multiple genes.
• Pharmacogenetics is the study of genetic variability of drug responses due to variation in single
genes.
• Pharmacogenetic and pharmacogenomic studies can potentially lead to drugs that can be tailor-
made for and adapted to each person’s particular genetic makeup.
Gene Therapy
• Gene therapy is an experimental technique that uses genes to treat or prevent disease.
• Although gene therapy is a promising treatment option for a number of diseases (e.g., inherited
disorders, some types of cancer), the technique remains risky and is still being studied.
STEM CELLS
• Stem cells are cells in the body that can differentiate into other cells. Stem cells can be divided
into 2 types: embryonic and adult.

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• Stem cells are the subject of much discussion because they may allow for the regeneration of lost
tissue and restoration of function in a variety of chronic diseases, such as diabetes, heart disease,
Alzheimer’s disease, rheumatoid arthritis, stroke, spinal cord injury, and burns.
Nursing Management: Genetics and Genomics
• By understanding the profound influence that genetics has on health and illness, you can help the
patient and family in making critical decisions related to genetic issues, such as genetic testing.
• You will collaborate with the health care team to involve a genetic counselor.
• You need to be able to give patients and their families accurate information about genetics,
genetic diseases, genetic risks, and probabilities of genetic disorders.
• Maintain the patient’s confidentiality and respect the patient’s values and beliefs because genetic
information may have major health and social implications.
• Genetic testing may raise many psychologic and emotional issues. Knowledge of carrier status of
a genetic disorder may influence a person’s career plans and decisions for marriage and childbearing.
• Ethical questions include: Who should know the results of a genetic test? Who should protect the
privacy of test results and prevent discrimination?
Family History
• Family history is one of the strongest indicators of a person’s risk of developing genetic related
disorders, such as heart disease and cancer.
• Knowing the family history can help in the early diagnosis and treatment of a disorder. For
example, it is important to monitor cholesterol levels in a person with a family history of familial
hypercholesterolemia.
• The family history may hold important clues about a person’s risk for a genetic disease. People
with a family history of disease may benefit from lifestyle changes (e.g., smoking cessation, healthy
nutrition) and screening tests for the early detection and treatment of disease.

Chapter 15
Infection
KEY POINTS
INFECTIONS
• An infection is an invasion of the body by a pathogen (any microorganism that causes disease) and the
resulting signs and symptoms that develop in response to the invasion.
• Infections can be divided into localized, disseminated, and systemic disease.
EPIDEMIOLOGIC CONCEPTS
• Incidence refers to the number of new cases of a health-related issue or problem occurring during a
specific time period.
• Prevalence refers to the total number of people who have a specific health-related issue, problem,
disease or illness at any given time.
• Epidemic refers to a rise or increase of a disease or condition within a certain community or area.
• Pandemic is a type of epidemic that has significant geographic spread and affects entire countries or
the world.
TYPES OF PATHOGENS
• The most common types of pathogens are bacteria, viruses, fungi, and protozoa.
• Agents cause infection in 2 ways: They grow inside human cells, causing damage, or they secrete
toxins that damage cells.
EMERGING INFECTIONS

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• An emerging infection is an infectious disease whose incidence has increased in the past 20 years or
threatens to increase in the immediate future. Examples include Ebola, MERS, H1N1, SARS, West
Nile virus, and Zika.
• Emerging infectious diseases can originate from unknown sources, contact with animal or insect
vectors, changes in known diseases, or biologic warfare. Global travel, population density,
encroachment into new environments, misused antibiotics, and bioterrorism have contributed to the
increased risk of emerging infections.
• Drug resistance occurs when pathologic organisms change in ways that decrease the ability of a drug
(or a family of drugs) to treat disease.
• Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and
penicillin-resistant Streptococcus pneumoniae are 3 of the most troublesome drug resistant bacteria
currently causing problems in North America.
HEALTH CARE-ASSOCIATED INFECTIONS
• Health care-associated infections (HAIs) are infections that are acquired from exposure to a
microorganism in a hospital setting.
• Around one third of HAIs are preventable through the implementation of health care precautions.
GERONTOLOGIC CONSIDERATIONS: INFECTION IN OLDER ADULTS
• The rate of HAIs is 2 to 3 times higher for older adult patients than for younger patients.
• Common infections in older adults include pneumonia, urinary tract infections (UTIs), and skin
infections.
INFECTION PREVENTION AND CONTROL
• Healthcare workers should be provided personal protective equipment (PPE) which are items that
prevent infection or injury to the wearer. PPE includes gloves, gowns, facial protection, and disposal
systems for sharps.
• The Occupational Safety and Health Association (OSHA) mandates that any employer whose
employees could be exposed to potentially infectious materials implement standard policies and
procedures for protection of those employees.
• The Centers for Disease Control and Prevention (CDC) developed guidelines with 2 levels of
precautions: standard precautions (designed for use during the care of all patients in hospitals and
health care facilities) and transmission-based precautions (designed for specific diseases).
COVID-19
• Human-to-human spread is through to be through respiratory droplets.
• Incubation period can be up to 14 days. People may transmit the infection and not show any
symptoms.
• Manifestations vary. Spectrum can be divided into categories: asymptomatic or presymptomatic, mild,
moderate, severe, and critical.
• Some people can develop post-acute COVID-19 syndrome and have symptoms that last more than 4
weeks.
• RT-PCR or NAAT testing is considered gold standard for diagnosis.
• Chest CT imaging may show diffuse may show opacities, in a small percent of people, imaging
studies may be normal.

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• Many patients can be managed as an outpatient. Hospitalization is required for people with more
severe illness or risk of complication.
• Monitor for signs and symptoms of respiratory or hemodynamic instability.
• Treatments include monoclonal antibodies and antiviral therapy.
• mRNA and viral vector vaccines can provide protection against COVID-19.
HUMAN IMMUNODEFICIENCY VIRUS INFECTION
• Human immunodeficiency virus (HIV) infection is a global pandemic.
• HIV can only be transmitted under specific conditions that allow contact with infected body fluids,
including blood, semen, vaginal secretions, and breast milk.
• Sexual contact with a person with a detectable HIV viral load is the most common mode of
transmission.
Pathophysiology
• HIV is a ribonucleic acid (RNA) virus, which replicates by using its RNA as a template to produce
deoxyribonucleic acid (DNA), which is then integrated into the human genome.
• Immune dysfunction in HIV infection is caused by damage and destruction of CD4+ T cells (also
known as T helper cells or CD4 cells).
• The major concern related to immune suppression is the development of opportunistic diseases
(infections and cancers that occur in immunosuppressed patients that can lead to disability, disease,
and death).
Clinical Manifestations and Complications
• HIV infection is divided into different stages, including acute, asymptomatic, symptomatic, and AIDS.
• Acute HIV infection occurs 2 to 4 weeks after the initial infection and is often accompanied by a
mononucleosis-like syndrome that may be mistaken for the flu.
• Asymptomatic infection is the interval between untreated HIV infection and a diagnosis of acquired
immunodeficiency syndrome (AIDS). Although called asymptomatic, symptoms (e.g., fatigue,
headache, low-grade fever, night sweats) often occur.
• Symptomatic infection occurs as the CD4+ T-cell count drops to 200 to 500 cells/μL, and the viral
load increases. Symptoms seen in earlier phases tend to become worse and other problems, including
infections, lymphadenopathy, and nervous system manifestations, may occur.
• AIDS is characterized by severe immune system suppression and CD4 cell counts of less than 200
cells/μL.
Diagnostic Studies
• The most useful screening tests for HIV are those that detect HIV-specific antibodies and/or antigens.
• Two important laboratory assessments monitor the progression of HIV infection: CD4 cell counts and
HIV viral load.
Interprofessional Care
• Interprofessional management of the HIV-infected patient focuses on (1) monitoring HIV disease
progression and immune function, (2) initiating and monitoring antiretroviral therapy (ART), (3)
preventing the development of opportunistic diseases, (4) detecting and treating opportunistic

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 diseases, (5) managing symptoms, (6) preventing or decreasing the complications of treatment, and (7)
preventing further transmission of HIV.
• The goals of drug therapy in HIV infection are to decrease the viral load, maintain or raise CD4 cell
counts, prevent the development of HIV-related symptoms and opportunistic diseases, and delay
disease progression.
• The major drug classifications for HIV include nucleoside/nucleotide reverse transcriptase inhibitors
(NRTIs), integrase inhibitors (INSTIs), protease inhibitors (PIs), nonnucleoside reverse transcriptase
inhibitors (NNRTIs), and entry/fusion inhibitors.
• Treatment regimens can have side effects and often interact with other medications.
• Management of HIV is complicated by the many opportunistic diseases that can develop as the
immune system deteriorates.
• Examples of opportunistic diseases include Pneumocystis jiroveci pneumonia (PCP),
Mycobacterium avium complex (MAC), and Kaposi sarcoma.
NURSING MANAGEMENT: HIV INFECTION
• Since HIV infection can be prevented, nursing care for people not known to be infected with HIV
should focus on preventing disease transmission.
• The first step is to assess the patient’s individual risk behaviors, knowledge, and skills.
• Based on the assessment, nursing interventions can then encourage the patient to adopt safer,
healthier, and less risky behaviors, particularly about sexual intercourse, drug use, perinatal
transmission, and work issues.
• The overriding goals of therapy for infected persons are to keep the viral load as low as possible for as
long as possible, maintain or restore a functioning immune system, improve the patient’s quality of
life, prevent opportunistic disease, reduce HIV-related disability and death, and prevent new
infections.
• Nursing interventions are based on and tailored to patient needs at every stage of HIV disease and can
be instrumental in improving the quality and quantity of the patient’s life.
• Nursing care can assist the patient to (1) adhere to drug regimens; (2) promote a healthy lifestyle that
includes avoiding exposure to other sexual and blood-borne diseases; (3) protect others from HIV; (4)
maintain or develop healthy and supportive relationships; (5) maintain activities and productivity; (6)
explore spiritual issues; (7) come to terms with issues related to disease, disability, and death; and (8)
cope with the frequent symptoms caused by HIV and its treatments.
• Teach patients and families about treatment options: (1) advantages and disadvantages of new
treatments, (2) dangers of nonadherence to therapeutic regimens, (3) how and when to take each drug,
(4) drug interactions to avoid, and (5) side effects to report to the HCP.
• While patients living with HIV share problems experienced by all people with chronic diseases, these
problems are worsened by negative social attitudes and stigma associated with HIV. Discrimination
related to HIV infection can lead to social isolation, dependence, frustration, low self-image, loss of
control, and economic pressures.
• Should the nurse be exposed to HIV-infected fluids, postexposure prophylaxis (PEP) with
combination ART can significantly decrease the risk of infection.

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